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HomeMy WebLinkAboutBaker Commodities, Inc. - 12/31/2020BUSINESS NAME: %i'tr✓ el^¢✓% MAIL ADDRESS:: %l S�GL�i7�lr ra TOWN: %Jr'%li//�r;rr;�l-A 81 NAME OF OWNER:Cgrt L:5 oV.n, BUSINESS TELEPHONE: Pil ��ra` EMAIL:/rs �J y (r%f✓�olrr PED ID/SS NO: FEE PER TRUCK: y Truck Registration number: Truck Registration number: tJ Truck Registration number: septage Truck Registration number: Truck Registration number: Board o f Health Town 6 Park f Mansfield Mansfield, MA 02048 V Haulers Application DATE: LICENSE NUMBER; 15 CELL: 1-,' 'I. NUMBERI _................................................:........... SEPTAGE PUMPERS.- 310 UMPERS:310 CMR 15;606 Equipment: No person shall Use equipment to re septic tanks or other offensive substances unless such equipment Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508 ......... I... ................. ........................................................ FOG PUMPERS: Town of Mansfield SOH Fats, Oft and Grease (I -'OG) Regulations Article 3, Section 9: As of January 1, 2019, all Septic/FOG Hauler ti will be required to have a Septlo/FOG Hauler Permit. Septic/FOG F part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording occurs for BOH records. I acknowledge that all pumpers will record the % Combined S All documents must be Completed signed and returned to the Heall Checks can be made payable to Town of Mansfield; M011 to.' Board Mansfield, MA 02048. SIGNATURE: j K-4 r .+ ZIP CODE: 01,ie 4,"_ P5—�/Ax:y /yJ% E AIL: F TRUCK($): Circle one: septage Circle one: Septage circle one: septage Circle one: septage Circle one: Septage FOG ove or transport the contents of privies, cesspool, or las first been inspected and approved by the Board of 010 TIME: 7:30AM-11:00AM FOXBORO 261- 7366, IF YOU CAN NOT MAKE THIS DATE cks that service systems in the Town of Mansfield ulersmust provide a list of all FOG customers as 3 he % Combined Solids and Grease when pumping lids and Grease on the onsite logs. Department with the appropHale payment. Health, Town of Mansfield, Slx park Row, Town ofMansfield - Board of Health Town of Mansfield 6 Park Row Mansfield, MA 02048 Septage/FOG Haulers Application DATE: BUSINESS NAME: `//��-e,JVIVgu 11,1 MAIL ADDRESS: f j'�✓jr/LsY�` TOWN: A, %j, llevl A STATE: NAME OF OWNER: G �" '-3✓�' ' °� BUSINESS TELEPHONE: ��� yCELL: EMAIL:�fs> 7; ✓ Q 1yc'1!i/lure•-SALT EMAIL: LICENSE NUMBER: ZIP CODE: 691f6' I:)-- C3 �7/Ax: py(f,S,v SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:OOAM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9: As of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048, SIGNATURE: DATE: FED ID/SS NO: NUMBER OF TRUCK(S): FEE PER TRUCK: j J / >5Y� Truck Registration number: ArAl Truck Registration number <C , Truck Registration number S' "j Truck Registration number: Truck Registration number: Circle one: Circle one: Circle one: Circle one: Circle one: Septage Septage Septage Septage Septage FOG SEPTAGE PUMPERS: 310 CMR 15.505 Equipment: No person shall use equipment to remove or transport the contents of prives, cesspool, or septic tanks or other offensive substances unless such equipment has first been inspected and approved by the Board of Health. TRUCKS INSPECTIONS: DATE: WEDNESDAY NOVEMBER 13, 2019 TIME: 7:30AM-11:OOAM PLACE: FOXBOROUGH DPW PARKING LOT, 70 ELM STREET, FOXBORO PLEASE BE THERE, OR CALL THE FOLLOWING NUMBER (508) 261- 7366, IF YOU CAN NOT MAKE THIS DATE FOG PUMPERS: Town of Mansfield BOH Fats, Oils and Grease (FOG) Regulations Article 3, Section 9: As of January 1, 2019, all Septic/FOG Hauler trucks that service systems in the Town of Mansfield will be required to have a Septic/FOG Hauler Permit. Septic/FOG Haulers must provide a list of all FOG customers as part of the permit application. PLEASE NOTE: Onsite logs must be kept at all locations recording the % Combined Solids and Grease when pumping occurs for BOH records. I acknowledge that all pumpers will record the % Combined Solids and Grease on the onsite logs. All documents must be completed signed and returned to the Health Department with the appropriate payment. Checks can be made payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048, SIGNATURE: DATE: 11 5 _ M19ila`.3Ci1`i1C;L is"jM1r:rt"' l( rPvtlGi`WT:ll68 6 r Registiir Ut Motor Vehtoles APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07101/2018 EXPIRATION DATE: 06/3012019 MAILING INFORMATION - IRP REGISTRANT INFORMATION — ACCTIFLEET/YEAR/SUPP: 758.1-2018-0 LEGAL NAME: BAKER COMMODITIES INC DBA NAME: ADDRESS: 134 BILLERICA AVENUE N BILLERICA, MA 01862 BAKER COMMODITIES INC PO BOX 132 N BILLERICA, MA 01862-0132 MOTOR CARRIER RESPONSIBLE FOR USDOT: 34909 _- NAME: BAKER COMMODITIES INC ADDRESS: 4020 BANDINI BLVD _] 5346 VERNON, CA 90058 VEHICLE INFORMATION _- PLATE: 95110 UNIT #: 5346 VIN: 3AKJGBDV6DSFG8867 PLATE TYPE: APN UNLADEN WEIGHT: 16820 VEHICLE TYPE: Tractor MAKE: FRHT FUEL: Diesel OWNER: BAKER COMMODITIES INC MODEL: 113 COLOR: White INSURANCE COMPANY: TRAVELERS INDEMNITY CO YEAR: 2013 SEATS: NA SERVICE REPRESENTATIVE: Jur ei J . Weight � Weight Jur Weight � Weight Jur Weight AB 36287k GA 80000 ME 80000 NJ 80000 PE 36287k WA 80000 AL 80000 IA 80000 MI 80000 NL 36287k CIC 5 AXLE WI 80000 AR 80000 ID 80000 MN 80000 NM 80000 RI 80000 WV 80000 AZ 80000 IL 80000 MO 80000 NS 36287k SC 80000 WY 80000 BC 36287k IN 80000 MS 80000 NV 80000 SD 80000 CA 80000 KS 80000 MT 80000 NY 80000 SK 36287k CO 80000 KY 80000 NB 36287k OH 80000 TN 80000 CT 80000 LA 80000 NC 80000 OK 80000 TX 80000 DC 80000 MA 80000 ND 80000 ON 36287k UT 80000 ** **** DE 80000 MB 36287k NE 80000 OR 80000 VA 80000 FL 80000 MD 80000 NH 80000 PA 80000 VT 80000 Issued under the authority of the Registrar of Motor Vehicles for the Control: 8001-1325-1676 Massachusetts Department of Transportation. � e �" Registrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. \ 25 Newport Ave EXt., 4th Floor �...' Quincy, MA 02171 Tel: (857) 368-8120 www.massrmv.com N! Y{9ii."�tc Flra;<uc:nrattsr)epertmentu47ranspenaaioo 6 DOT Registry of Motor Vehicles APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 0710112018 EXPIRATION DATE: 06/3012019 MAILING INFORMATION IRP REGISTRANT INFORMATION ACCT/FLEETNEAR/SUPP: 756-1-2018-0 LEGAL NAME: BAKER COMMODITIES INC DBA NAME: LERICA AVENUE RICA, MA 01862 BAKER COMMODITIES INC 95642 PLATE TYPE: APN MAKE: FRHT PO BOX 132 =MOTORCARRIERESPONSIBLE YEAR: N BILLERICA, MA 01862-0132 WeightAB 24493k FOR 54000 USDOT: 34909 NJ NAME: BAKER COMMODITIES INC 24493k ADDRESS: 4020 BANDINI BLVD 54000 VERNON, CA 90058 PLATE: 95642 PLATE TYPE: APN MAKE: FRHT MODEL: 114SD YEAR: 2015. UNIT*UNLADEN Weight WEIGHT: 18508 FUEL: Diesel COLOR: White SEATS: NA VIN: VEHICLE TYPE: OWNER: INSURANCE COMPANY: SERVICE REPRESENTATIVE: 1FVHG3DV7FHGP3956 Truck BAKER COMMODITIES INC TRAVELERS INDEMNITY CO jur Weight Ju[ Weight Jur Weight J�tr Weight SILL Weight l,�lr WeightAB 24493k GA 54000 ME 54000 NJ 54000 PE 24493k WA 54000AL 54000 IA .54000 MI 54000 NL 24493k QC 5 AXLE WI 54000AR 54000 ID 54000 MN 54000 NM 54000 RI 54000 WV 54000AZ 54000 IL 54000 MO 54000 NS 24493k SC 54000 WY 54000BC 24493k IN 54000 MS 54000 NV 54000 SD 54000* 54000 KS 54000 MT 54000 NY 54000 SK 24493kCO **k*CA 54000 KY 54000 NB 24493k OH 54000 TN 54000CT 54000 LA 54000 NC 54000 OK 54000 TX 54000DC 54000 MA 54000 ND 54000 ON 24493k UT 54000DE 54000 MB 24493k NE 54000 OR 54000 VA 54000FL 54000 MD 54000 NH 54000 PA 54000 VT 54000 Issued under the authority of the Registrar of Motor Vehicles for the Control: 8001-1325-1867 Massachusetts Department of Transportation. (.:u,� eRegistrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. / /i in /- /e 25 Newport Ave EM., 4th Floor Quincy, MA 02171 Tel: (857) 368-8120 www.massrmv.com Ri?}i:c} erjppatm ent et 1'ezn3portatiaa hr Registry of Motor Vehicles APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 07/0112018 EXPIRATION DATE: 06/3012019 MAILING INFORMATION - IRP REGISTRANT INFORMATION -- ACCT/FLEETIYEAR/SUPP: 758-1-2018-0 LEGAL NAME: BAKER COMMODITIES INC DBA NAME: BAKER COMMODITIES INC ADDRESS: 134 BILLERICA AVENUE N BILLERICA, MA 01862 PO BOX 132 N BILLERICA, MA 01862-0132 MOTOR CARRIER RESPONSIBLE FOR USDOT: 34909 NAME: BAKER COMMODITIES INC I ADDRESS: 4020 BANDINI BLVD VERNON, CA 90058 PLATE: 90563 UNIT#: 3549. VIN: 1FDUF5GT4DEB09613 PLATE TYPE: APN UNLADEN WEIGHT: 7555 VEHICLE TYPE: Truck MAKE: FORD FUEL: Diesel OWNER: BAKER COMMODITIES INC MODEL: F550 COLOR: White INSURANCE COMPANY: TRAVELERS INDEMNITY CO YEAR: 2013 SEATS: NA SERVICE REPRESENTATIVE: Jur Weiaht JZ Weigh J.Ur Weigh M Weight Jur Weight Jur Weighs AB 9071k GA 20000 ME 20000 NJ 20000 PE 9071k WA 20000 AL 20000 IA 20000 MI 20000 NL 9071k QC 4AXLE WI 20000 AR 20000 ID 20000 MN 20000 NM 20000' RI 20000 WV 20000 AZ 20000 IL 20000 MO 20000 NS 9071k SC 20000 WY 20000 BC 9071k IN 20000 MS 20000 NV 20000 SD 20000 CA 20000 KS 20000 MT 20000 NY 20000 SK 9071k CO 20000 KY. 20000 NB 9071k OH 20000 TN 20000 CT 20000 LA 20000 NC 20000 OK 20000 TX 20000 DC 20000 MA. 20000 ND 20000 ON 9071k UT 20000 ** **** DE 20000 MB 9071k NE 20000 OR 20000 VA 20000 FL 20000 MD 20000 NH 20000 PA 20000 VT 20000 Issued under the authority of the Registrar of Motor Vehicles for the Massachusetts Department of Transportation. CJt��u e �� Registrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 25 Newport Ave EM., 4th Floor �. Quincy, MA 02171 Tal: (857) 368-8120 www.massnnv.com Control: 8001-1325-1906 5` f�� ffi. ® 8 t�esi.hus -an yeain,m^{u67tzn3�uefiYi4n i Registry of Motor vehicles APPORTIONED REGISTRATION CAB CARD EFFECTIVE DATE: 0710112018 EXPIRATION DATE: 06130/2019 MAILING INFORMATION - IRP REGISTRANT INFORMATION — ACCTIFLEETIYEARISU PP: 758-1-2018-0 LEGAL NAME: BAKER COMMODITIES INC DBA NAME BAKER COMMODITIES INC ADDRESS: 134 BILLERICA AVENUE N BILLERICA, MA 01862 PO BOX 132 N BILLERICA, MA 01862-0132 USDOT: 34909 NAME: BAKER COMMODITIES INC ADDRESS: 4020 BANDINI BLVD VERNON, CA 90058 JZ Weight Jur Weight JZ Weight Jut Weight Jur VEHICLE INFORMATION PLATE: 79553 UNITM 3548 VIN: 3C7WRMCL4HG547960 PLATE TYPE: APN UNLADEN WEIGHT: 7419 VEHICLE TYPE: Truck MAKE: MODEL: DOOG Ram FUEL: COLOR: Diesel White OWNER: INSURANCE COMPANY: BAKER COMMODITIES INC TRAVELERS INDEMNITY CO YEAR: 2017 SEATS: NA SERVICE REPRESENTATIVE: NL 11793k QC 4 AXLE WI 26000 AR JZ Weight Jur Weight JZ Weight Jut Weight Jur WeighS Jur Weigh AB 11793k GA 26000 ME 26000 NJ 26000 PE 11793k WA 26000 AL 26000 IA 26000 MI 26000 NL 11793k QC 4 AXLE WI 26000 AR 26000 ID 26000 MN 26000 NM 26000 RI 26000 WV 26000 AZ 26000 IL 26000 MO 26000 NS 11793k SC 26000 WY 26000 BC 11793k IN 26000 MS 26000 NV 26000 SD 26000 '** CA 26000 KS 26000 MT 26000 NY 26000 SK 11793k CO 26000 KY 26000 NB 11793k OH 26000 TN 26000 CT 26000 LA 26000 NC 26000 OK 26000 TX 26000 ** **** DC 26000 MA 26000 ND 26000 ON 11793k UT 26000 ** **** DE 26000 MB 11793k NE 26000 OR 26000 VA 26000 FL 26000 MD 26000 NH 26000 PA 26000 VT 26000 Issued under the authority of the Registrar of Motor Vehicles for the Maassachuuseftsl'Department of Transportation. J� & e Registrar ORIGINAL MUST BE CARRIED IN VEHICLE AT ALL TIMES. VOID IF ALTERED. 25 Newport Ave Ext., 4th Floor Quincy, MA 02171 Tel: (857) 368-8120 www.massnnv.com Q% 66 � Control: 8001-1325-1388 l'�� � --' ` Qy��`dCP, 0�1I9aErd5tr8taeavrey 600 WashilligiOn Slyeef a — Bosion, IIIA 02111 avvvw. cnass.®ov/dia Workers' Cooripensation Insurance AfffidavR: General Busi nesses Busitress/Organization Name: Sul:?r OYYIY�oCti'iiC�� nC — Address: \TOVIIIIIIIII ]tZC1 lel .bre you an employer? Check the appropriate box: 1. 1 am a employer with �ti employees (full and/ or part-time),* 2. [J 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] We are a corporation and its officers have exercised their right of exemption per c, 152, § 1(4), and we have no employees.- (No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees, [No workers' comp, insurance req.] Business Type (required): 5. ❑ Retail. 6. ❑ Restaurant/BadEating Establishment 7. ❑ Office and/or Sales (incl. real estate, auto, et 8. ❑ Non-profit 9. ❑ Entertainment 10.❑ Manufacturing I1,7 Health Care 12.0 Other SerV I CC "Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. "If the corporate officers have exempted themselves, but the coiporation has other employees, a workers' compensation policy Is required and such an �. organization should check box til. f am an employerthat is providing workers' cornpettsadoit insurance for my employees, Below is the policy inforrnati Insurance Company Insurer's City/State/zip; Policy # or Self -ins. Lic, # Expiration Date: Attach a copy of the workers' compensation poucy declaration page (showing the policy number and expiration da Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties tine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and of up to $250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. N do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct Signature: t6eia0. �k Date: �c Phone#: 9723- 2Li—iR1l Official use only. Do riot ilwite in this area, to 6G completed by city or town official, City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2, ]Building Department 3, City/Town Clerk 4. (Licensing Board 5. Selectmen's Office Form W-9 Request for Taxpayer owe For, to the Identiflcatlon Number and Certification requester. a othe Asa namoHheoneury ► G0 to wwwane.govIrortwe toy instructions and the latest Inforrnetion. ttevenue Service to / qMw (as shown on your hmoolne tax ream ,Name requNed on mle Yne; do not laevo this the blank. W 4 Duskwee nameldieregerd entity name, H def t om above 3 Cheek SPpmPride box for federal tax classification of the person whose name Is entered on Zin7fl"LLC one of the 4Fxem1 ain entities, not kldlvltlueh; " apply sea iNbwhs seven boxes. rn�// Innnwtions an page 9): [] Yxaviduaveols proprietor or lie uCorpcmtbn ❑ SCapwaaan (3 PartnershrusVeAsle dngbtnembar LLC fix poles code Of amp (] IAnaed liability compamy. Ester the tax ciassi8aatlon(0-0 corporation, 8.8 COnaoraaon, N Note; Check the appropriate box In the line above for the tax daasxketen of the a rill o nat ohack Fxemplbn trpn FATCA report LLC N the LLC k clesaHled tie a einglo-member LLC mat a disregarded loom the owner unlef the LLC Is coda of any) another LLC that Is net dluesarded ham the owner is V�Se ul the tax � 1 on LLC that or Is deregarded from me Owner should check the epProM „n.a.vrmwn•n•eamawuai Other lsee lnatNptlMa)► 1 ���•. !,equeatpr'a name ane iddraaafWlYCaaY ... Pmdrrss (numtxmr, iVeeL-aadaf>L or n/^1]'�' r -. .. . 11Z 8? /-t A- d i IN in the appyopdote box. The TIN provided must match the name given on line 1 to avoid holding. For Indlvidi ls, this is generally your social securhy number (SSN). However, for a n, sole proprietor, or disregarded entity, see the instructions for Pert I, later. For other your employer Identification number (EIN). If you do not have a number, see How to get e urn, w,w. Note: If the account is In more than one name, see the instructions for line 1. Also see Whet Name and Number To Gtve the Requester for guidelines on whose number to enter, Under penatdes of perjury, I cenay mar. 1. The number shown on this form Is my correct taxpayer Identification number (or I am wailing for a number to be issued to me); and 2.1 am not subject to backup withholding because: (a) I am exempt from backup wfihhotding, or (b) I have not been notified by the Internal Revenue Service longer (I subject to backup at I amsubject twithholding; and holding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am 3.1 am a U.S. cid¢en or other U.S. person (defined below); and 4, The FATCA ccools) entered on this form of any) Indicating that I am exempt from FATCA reporting b correct. Certification inebudlots. you must Groes out hem 2 above If you have been notified by the IRS that you are curtemly subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition w abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement jiM and generally, paytneMs other than Internet and dividends. You are not required to sign the certification, but you you must provide your correct TIN. Sethe instnwgone (Griped41w ed 11e• algnI Gianat"of Here ` u.s. person General Instructs Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about devolopmenls related to Form W-9 and Its Instructions, such as legislation enacted atter they were published, go to www.ira.govyFomrWg. Purpose of Form An Individual or entity (Forth W-9 requeSter) who is required to flit) an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) whloh may be your social security number (SSN), Individual taxpayer identification number (ITiN), adoption taxpayer dentl9cation number (ATIN), or employer Identification number (Elft, to report on an Information return the amount paid to you, or other ramount eturns include, but are noobts On On tlimitedto, the following.ation return. les of Information • Form 100 -INT gntamt eamed or pold) Date to Vr JA • Form 1099 -DIV (dividends, Including those frordstocks or mutual funds) • Form 1099-MISC (various types of Income, prizes, awards, or gross proceeds) • Form 1099-8 (stock or mutual fund Sales and certain ether transactions by brokers) • Form 1099-S (proceeds from real estate trenwciions) • Form 1099-K (merchant card and third parry network transactions) • Form 1095 (home mortgage Interest), 1098-E (student ban Interest), 1o95 -T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only it you are a U.S, person Qncluding a resident alien), to provide your correct TIN. if you do not return Form W-9 to the requester with a 77N, you might be subject to backup withholding. See What is backup withholding, later. est. No. 102311 Form, W-9 (Ree. 102018) ACC o® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 64/02/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the ceruncate holder is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH RISK & INSURANCE SERVICES 777 SOUTH FIGUEROA STREET CA LICENSE 80437153 LOS ANGELES, CA 90017.5822 Attn: LosAngeles.CeORequest@marsh.Com/F: 212-948-0535 CN10314282513AKER-GAWU-19- Baker None CONTACT NAME: _ PHONE FAX AAC. No.INC, No: ADDRESS: IN3URERI5I AFFORDING COVERAGE NAICa -- -- INSURER A: Property Casually Co. of America 25674 _ _ INSURED BAKER COMMODITIES INC. B. C. DRAIN SERVICE, INC. INSURER B: NIA WA -- INSURER c: The Travelers Indemnity Company - INSURER D: THE GREASE COMPANY ISLAND PUMPING AND SERVICES, INC. 4020 BANDINI BOULEVARD INSURER E- INSURER F: VERNON, CA 90058 ---..}svcnwr_ec CFRTIFICATF NIIMRFR• LOS -00221664644 REVISION NUMBER' THIS IS TO CERTIFY THATTHE'POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /NSR TYPEOFINSUILI ADDL SUBR POLICY NUMBER POLICY EFF (MMADOIYY POLICY EXP MMIO LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE rx I OCCUR X X TC2JGLSA419J6422-TIL-19 04101/2019 0410112020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Eao encs $ 100,000 MED EXP (Any one person) E 5'000 PERSONAL&AOV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: — X CT LOC POLICY [:] jE OTHER: 00 GENERAL AGGREGATE $ 2'0'0X) 100,000 $ • A AUTOMOBILE LIABILITY % ANY AUTO X OWNED SCHEDULED AUTOS ONLY AUTOS X HIRED % NON -OWNED AUTOS ONLY AUTOS ONLY X X TC2JCAP419J6434-TIL-19 TC2JCAP419J6446-TIL. TC2J130419J646A-TILAS APD Comp/Coll Deductible: $25,000 0410112019 04/0112019 0410112019 04101/2020 04/01/2020 104101/2020 COMBINED SINGLE LIMIT $ 1,000,000 Ee eccidenl BODILY INJURY (Per person) $ BODILY INJURY /Per eccidenp $ PROPERTY DAMAGE ar accitlenl $ — $ I UMBRELIALIAB EXCESS UAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTIONS $ A C WORKERS COMPENSATION AND EMPLOYERS'LIABIUTY ANYPROPRIETORIPARTNERIEXECUTIVE Ya OFFICERIMEMBEREXCLUDEDP (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA X UBOM2542341951K10401/2020 UB8L7551251951R 0410112019 04/01/2020 X STATUTE ERH E.L. EACH ACCIDENT E 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1'000'000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 i I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) With the exception o(Workers' Compensation and Employers' Liabllity, Certificate Holder is included as additional Insured but only as respects liability arising out of the work performed for them by the named insured as required by written contract. The insurance afforded by these policies is primary and non contributory with any insurance maintained by the additional insured, but only as respects the work performed for them by the named insumd as required by written contract. Waiver of subrogation is provided in favor of the cedificate holder as required by written contract. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & luau ranca Services Janice Hsu © 1988.2016 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD Christopher George From: Shawn Ordway <SOrdway@bakercommodities.com> Sent: Monday, November 4, 2019 8:44 AM To: Christopher George Subject: RE: [EXTERNAL] - RE: [EXTERNAL] - RE: [EXTERNAL] - RE: Emailing: Scan Baker Commodities Yes, we acknowledge the requirements Shawn P. Ordway Sales & Customer Relations Representative pftw 4 & Braker Commod'rfies Inc. Recycling far Life Baker Commodities Inc. 134 Rear Billerica Ave. North Billerica, MA 01862 Office: 978-454-8811 Cell: 603-566-4410 http://www.bakercommodities.com Please consider the environment before printing this email. From: Christopher George[mailto:cgeorge@mansfieldma.com] Sent: Monday, November 04, 2019 8:38 AM To: Shawn Ordway Subject: [EXTERNAL] - RE: [EXTERNAL] - RE: [EXTERNAL] - RE: Emailing: Scan Baker Commodities Hi Shawn, I will print off this email and retain it with your application. There is a section of the Application that asks you to check off your establishments understanding of the Health Departments requirements with FOG. Please respond to this email that you verify your establishment's understanding of that statement in lieu of having that box checked and I will keep your response with the application. Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 From: Shawn Ordway [mai Ito: SOrdwayno bakercommodities.com] Sent: Monday, November 4, 2019 8:34 AM To: Christopher George Subject: RE: [EXTERNAL] - RE: [EXTERNAL] - RE: Emailing: Scan Baker Commodities Chris, Good morning, below is a list of the customers we service in Mansfield... -Fresh Catch -Jimmy's Pub -TGI Friday -Mansfield Country Square at 321 School St (Hilliards, Whites Bakery & Buffalo Wild Wings), these are not individual accounts, they are all done for the property owner (Keypoint Partners). -Orange Leaf Shawn P. Ordway Sales & Customer Relations Representative ANVAL Baker Commodities Inc. Recycling for Ufa Baker Commodities Inc. 134 Rear Billerica Ave. North Billerica, MA 01862 Office: 978-454-8811 Cell: 603-566-4410 httr)://www.bakercommodities.com Please consider the environment before printing this email From: Christopher George fmailto•cgeorae mansfieldma.com] Sent: Monday, November 04, 2019 8:10 AM To: Shawn Ordway Subject: [EXTERNAL] - RE: [EXTERNAL] - RE: Emailing: Scan Baker Commodities Hi Shawn, Attached is our Septage Pumper/Hauler Packet. If you have any questions, please feel free to contact me via phone or email. Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 From: Shawn Ordway[mai Ito: SOrdway@bakercommod ities.com] Sent: Friday, November 1, 2019 2:38 PM To: Christopher George Subject: RE: [EXTERNAL] - RE: Emailing: Scan Baker Commodities Hi Chris, Ken Fournier is on vacation and asked if I could send you the updated hauler application but I didn't get the attachment. Could you send that to me please so I can get it filled out for you? Thanks, Shawn P. Ordway Sales & Customer Relations Representative _ 'Baker Commodities Inc. Recycling for Life Baker Commodities Inc. 134 Rear Billerica Ave. North Billerica, MA 01862 Office: 978-454-8811 Cell: 603-566-4410 http://www.bakercommodities.com Please consider the environment before printing this email. -------- Original message -------- From: Christopher George <c eor e cr,mansfieldma.com> Date: 10/30/19 2:08 PM (GMT -05:00) To: Ken Fournier<KFournier@bakercommodities.com> Subject: [EXTERNAL] - RE: Emailing: Scan Hello Mr. Fournier, I was reviewing your application and there is a section missed. Please check under the section labeled FOG PUMPERS on the Main Septage/FOG Haulers application and provide the requested list of all FOG customers. Please let me know if you have any questions. Thank you, -Chris George Administration Assistant Public Health Department, Town of Mansfield 508-261-7366, Ext. 66463 -----Original Message ----- From: Ken Fournier [mailto:KFournier abakercommodities.com] Sent: Wednesday, October 30, 2019 11:15 AM To: Christopher George Subject: FW: Emailing: Scan Ken Fournier Customer Relations Representative Trap Grease manager Baker Commodities Inc. Billerica Ma, P.O. Box 134 Billerica Ave, N. billerica MA 01862 978-654-7715 978-454-8811 kfourrlier@bakercommodities.com Please consider the environment before printing this email. -----Original Message ----- From: Ken Fournier Sent: Wednesday, October 30, 2019 11:13 AM To: Ken Fournier Subject: Emailing: Scan Your message is ready to be sent with the following file or link attachments: Scan Note: To protect against computer viruses, e-mail programs may prevent sending or receiving certain types of file attachments. Check your e-mail security settings to determine how attachments are handled. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. CONFIDENTIAL NOTICE: This e-mail communication and any attachments may contain proprietary and privileged information for the use of the designated recipients named above. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. CONFIDENTIAL NOTICE: This e-mail communication and any attachments may contain proprietary and privileged information for the use of the designated recipients named above. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Disclaimer The information contained in this communication from the Town of Mansfield is confidential. It is intended solely for use by the recipient and others authorized to receive it. If you are not the recipient, you are hereby notified that any disclosure, copying, distribution or taking action in relation of the contents of this information is strictly prohibited and may be unlawful. This email has been scanned for viruses and malware, and may have been automatically archived by Mimecast Ltd, an innovator in Software as a Service (SaaS) for business. Providing a safer and more useful place for your human generated data. Specializing in; Security, archiving and compliance. To find out more Click Here. CONFIDENTIAL NOTICE: This e-mail communication and any attachments may contain proprietary and privileged information for the use of the designated recipients named above. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.